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According to his uncle Inche Mat Saman bin Yit, Ismail was an intelligent and talkative person, but some time in 1949 he got seriously ill, and after his recovery became irrational and refused to talk. In this condition he visited his neighbour Haji Jagara twice at 3 a.m., which he was said to have never done before, and on one occasion asked for some holy water against a burning sensation in his head and chest. According to his wife Aisah Ismail complained often about this ailment, was restless, and could not eat, or sleep.

His uncle Inche also related that Ismail's grandfather, as well as another of his uncles suffered from mental illness, and that they feared he could become insane like them.[2]

On the evening of November 4, 1949 Ismail supposedly had a dispute with the Chinese shoopkeeper of a provisional shop about the price of some goods. During the argument Ismail pulled out a golok, attacked the shopkeeper, and also turned against the other customers.[3]

He then rushed out into the street, where he continued to stab people at random. On his way he came across Looi Ah Seng, who was sitting outside his house, and whom he chased through the street, before fatally stabbing him in the stomach. Afterwards he entered the shop of Heng Swee Kheng, stabbed Heng's younger brother, and later on attacked goldsmith Ng Loon Cheng in front of a coffee-shop, injuring him in the left forearm.[4]

In total four Chinese men died at the scene, while seven or eight other people were wounded, among them three women. A fifth man succumbed to his injuries seven hours later in hospital, and a sixth on the morning of November 6, while Tan Sai Way, one of the injured women, died during the night to November 7.

Ismail was eventually subdued by police and sent to the mental hospital in Tanjong Rambutan for observation.[5] On March 3, 1950 the 42-year-old was found to have been insane at the time of the murders and was ordered to be kept in Penang prison.[2]